Chiropractors certified in flexion-distraction help to

MIRACLE
Workers
By Renee Diiulio
F
lexion-distraction is one of the most well-researched chiropractic techniques currently in use. This could be in part attributed to its age: the
technique, known as the Cox Technic, was developed in the 1960s by
James M. Cox, DC, DACBR, and has had constant improvement since
then. Many chiropractors are exposed to the
technique in school, where they often learn the
very basics. Yet there is much more to learn that
can impact the success of treatment.
Those who decide to pursue Cox Technic certification obtain advanced training that assures that any
certified practitioner provides completely consistent
care. Movements, pressure, and placements are all the
same. (Computer programs measuring these factors
are used during educational seminars to ensure uniformity.) Use of the technique is often maximized, as
are the results.
“We get miraculous results because treatment is very specific to the area,” says Mike M.
Poulin, DC, Cox recertified, Poulin
Chiropractic, a practice with two locations in
Virginia (Herndon and Ashburn). Poulin is a
true believer—he attributes his mobility today
to the Cox Technic.
“If it wasn’t for Cox Technic I wouldn’t be able
to treat the number of patients I do, especially as busy
as our two practices are today. I’d probably be on disability,” Poulin says.
The Pains
Chiropractors certified in
flexion-distraction help to
relieve the misery of and
restore function in patients
with back pain (and even
arm, leg, and neck pain, too).
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chiropub.com • November 2008
Poulin suffered
from a condition many
Cox Technic patients
share: back pain resulting from a herniated disk. Cox Technic
decompression provides relief of spinal
pain due to disk herniation and stenosis,
facet
syndrome,
spondylolisthesis,
synovial cyst, sciatica and leg pain,
whiplash, headache, arm pain, and neck pain.
Contraindications include fractures, open wounds, and infections, but because the method is so gentle, there are few other
contraindications.
Poulin sees a lot of lumbar disk herniation; cervical, thoracic, and lumbar stenosis; scoliosis; and facet issues that respond to Cox. “We are even starting to see things you would
not normally consider, such as fragment disk prolapses,”
Poulin says.
Leisa-Marie Grgula, BS, DC, a chiropractic physician
with the Accurate Care Pain Relief Center in Phoenix, who is
also recertified in Cox, believes that Cox Technic has always
had a wide range of applications and notes that founder Cox
uses the technique almost solely in his practice. Grgula uses
Cox on about 80% of her patients (she sees an average of
about 40 patients per day).
Alfred Furtado, DC, co-clinical director at Shoreline
Spine and Pain Associates, PC, in Guilford, Conn, does not
employ Cox quite as much—on only 40% to 50% of his average 100 patients per week—but still believes in its efficacy.
“Not all patients respond, but there has been some good literature that demonstrates its efficacy. It’s important to be aware
of the literature that exists and what the indications are for
flexion-distraction,” Furtado says.
The Benefits
Cox Technic offers summaries of and links to some of
the existing literature on its Web site, particularly those studies funded by federal grants. In one such project focused on
biomechanics, researchers at the National University of
Health Sciences (Lombard, Ill), in cooperation with the
Loyola University Chicago Stritch School of Medicine, determined that flexion-distraction allows the reduction of intradiskal pressure (to as low as -192 mm Hg), an increase in
intervertebral disk height, and an increase in intervertebral
foramen size by 28%.1
In another study, the team found that flexion-distraction
did significantly better than physical therapy for chronic/severe, chronic/acute, and radiculopathy patients. (Physical
therapy, however, had better results with chronic/recurrent
back pain.)
Flexion-distraction is comprised of doctor-applied pressure at specific contacts intended to relieve pain, realign the
spine, and/or restore range of motion. Because it is controlled
by the doctor, the process can be very gentle and therefore applied to weaker patients, such as the osteoporotic and fused
postsurgical patients.
“You can’t do a typical adjustment on a 90-year-old lady
with osteoporosis without breaking something, but with Cox,
you can decompress very gently. If someone comes in with
severe pain, you can start out very gently. We always tolerance test every patient and start the technique slow,” Poulin
says. But the effort is still specific.
“The doctor can have a hand specifically in place on the
spine and isolate one or two vertebra. So if we want to isolate the
L5 vertebrae, we set up on the vertebra above L4,” says Poulin,
who contrasts this methodology with typical decompression,
with which the entire spine is treated.
The Results
The technique can produce amazing results, and if it does
not, then the strict Cox Technic practitioner will stop trying. The
method’s protocols require improvement. “If we do not find
50% relief within 4 weeks, we refer the patient to another medical discipline, such as a neuroconsult,” Grgula says.
If that relief has been achieved, then the number of visits is
reduced and the process is repeated. “We don’t go past 12 visits if the patient is not 50% better. We’ll do something else—an
MRI or neurosurgical consult, for example,” Poulin says.
The treatment plan is therefore constantly changing in response to the patient’s condition. Goals may represent a shifting
pattern of pain reduction and restoration of function. Pain relief
often comes with the reduction of pressure on the cord or peripheral nerve. “Outside of pain relief, we basically want to restore function to the levels in question,” Grgula says.
“If a patient can only sit for 5 minutes, we want them to be
able to sit for 10 minutes, then 20 minutes, and up. We want to
get them to where they can sleep and restore their quality of
life,” Poulin says.
The focus on results gets the attention of both patients and
physicians, and many certified Cox Technic practitioners find
their schedules are kept full primarily through referrals from patients, physicians, and even other Cox practitioners. Certified
Cox practitioners are more comfortable referring to one another because the shared learning ensures that the patient will receive the same therapy.
The Table
The volume helps to support the proper equipment. While
a Cox Table is not necessary, those who do have them swear by
them. “The majority of cases we see are so much more complicated and chronic that I don’t think the traditional treatment
would work. If a disk is torn, we can’t side posture someone
without making it worse,” Poulin says.
The Cox Table is now in its seventh generation and has
been modified in response to research as well as user feedback.
The Cox7Table is available through Track Corp in Spring Lake,
Mich, and has been designed to use the doctor’s hands as a
guide while protecting the doctor ergonomically. (For instance,
a ball hand grip for adjustments rather than a “T” reduces wrist
and hand stress.)
Adjusting features permit chiropractors to perform flexion,
extension, lateral flexion, circumduction, and rotation (cervical)
movements with or without long y-axis distraction; smooth, safe
full-spine distraction; and manual and automated long y-axis
cervical, thoracic, and lumbar spine traction. Segments include
November 2008 • chiropub.com
19
Tools of the Trade
Do your homework before making a decision on which flexion-distraca cervical axial, long Y-axis distraction headtion table is right for your practice. The following manufacturers offer
piece (newly patented); a free-floating, smooth
some of the more popular flexion-distraction tables available.
cervical spine distraction unit; an optional thoChattanooga Group
Lloyd Table Co
racic drop; and an adjustable face piece with an
4717 Adams Rd
102-122 W Main St
eye socket cutout for patient ease of breathing
Hixson,
TN
37343
Lisbon, IA 52253-0899
and nose and eye comfort.
(800) 592-7329
(800) 553-7297
Flexion-distraction tables are also available
(800) 242-8329 fax
(319) 455-2166 fax
from manufacturers such as Hill Laboratories,
www.chattgroup.com
sales@lloydtable.com
Eurotech, and Lloyd Table Co. Hill Laboratories’
www.lloydtable.com
Air-Flex is an electric adjustable-height treatEurotech Tables
ment table that features air-powered flexion and
1521 Ninth Ave SE, Suite 3
Track Corp
distraction.
18438 171st Ave
Watertown,
SD
57201
“All manual flexion tables have to be counSpring Lake, MI 49456
(800) 743-7738
terbalanced for the patient’s weight,” says Hill
(616) 850-8630
www.eurotechtables.com
Laboratories, Frazer, Pa, president Howard Hill,
(616) 850-8621 fax
who points out that the Air-Flex uses a pneumatHill Laboratories Co
info@coxtable.com
ic system.
3 Bacton Hill Rd
www.coxtable.com
“We chose a pneumatic system for our taFrazer, PA 19355
bles because it is so reliable and easy to use,”
Williams Healthcare Systems
(877) 445-5020
Hill says. When the patient is on the table, the
158 N Edison Ave
(610) 647-6297 fax
flexion cylinder can be rapidly increased or deElgin, IL 60123
sales@hilllabs.com
creased with air so that the weight of the pa(800) 441-4967
www.hilllabs.com
tient can be counterbalanced. Little force to
(847) 741-3661 fax
flex the table is then required even on the heavinfo@williamshealthcare.com
iest patient.
www.williamshealthcare.com
With the air compressor built right into the
electrical elevation base, it is also used to create
distraction. Hill even has an optional feature
(auto-distraction) that allows the doctor to automatically cycle the traction-decompression.
“The compressor also enables us to offer
pneumatic drops on the table. Instead of hand
levers, we use the air system to activate any one
of four drops on the table,” Hill notes. Its tables
on-bone lumbar L5 disk, but now, it’s three times the size
also feature an air-powered, abdominal thoracic breakand looks normal,” Poulin says. CP
away as well as an optional cervical flexion headpiece for
manual flexion on the cervical spine. Manual and autoRenee Diiulio is a contributing writer to Chiropractic
flexion options are also available; the doctor need only
Products. For more information, contact CPeditor@
move a lever to convert the Air-Flex from manual mode to
ascendmedia.com.
automatic.
The Air Flex gives you a lot of versatility to treat paReference
tients,” says Hill, who notes that the Air-Flex can be cus1. Cox Technic. Funded Projects Completed & Underway. The
tomized to the doctor’s needs.
Research. Available at: www.coxtechnic.com/research.asp. Accessed
“What makes any table flexion-distraction is that it alOctober 1, 2008.
lows us to do the technique properly and document the protocols used on each specific condition,” Grgula says.
Flexion-distraction tables can be used alone or in conjunction with electrical stimulation, ice/heat, ultrasound, and
strengthening exercises. The intent is to enhance clinical
outcomes.
Properly applied, the Cox Technic can provide that
benefit, and many patients respond who have not had luck
with previous methods. Poulin recalls that he discovered
Cox after surgery and reinjury drove him to find the “best
possible treatment” for his back. “My disk used to be bone-
Learn how to use a
flexion-distraction
table—read the March
2007 Archive at
www.chiropub.com.
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chiropub.com • November 2008